3.2.2 Physicians’ university education Physicians’ university education is discussed as an influence on decision making, because attending university, studying medicine and passing the German state exams are the prerequisites for being allowed to work as a medical practitioner in Germany. Furthermore, the studies towards obtaining a medical degree, in most cases, provide the first practical experience of future doctors and additionally extend over a considerable length of time i.e. minimum of six years. Both the length and the experience communicated by the studies are likely to be strong influences on the future economic decision making of doctors. In the context of mental models, education consequently has to be assumed as a key variable which potentially shapes physicians’ economic decision making behavior.63 The goals and objectives of the studies towards obtaining a medical degree in Germany are outlined in Article 1.1 of the Approbationsordnung für Ärzte (ÄApprO). Students who want to earn a medical degree in Germany need to fulfill the criteria laid down in Art. 1.2 ÄApprO during the time of their studies. Universities which want to offer medical degrees have to adhere to the rules laid down in the ÄApprO and follow the structure of its standardized curriculum.

The curriculum is split into two parts. The Vorklinikum provides prospective medical practitioners with an understanding of natural- and socio-scientific principles of medicine and an insight into the functioning of a healthy human body. The Vorklinikum is concluded by the first of two major exams scheduled under Art. 1.2 ÄApprO and which are obligatory to obtain a medical degree. The Klinikum consists of specialization courses, which are provided for by statute under Art.27 ÄApprO. In addition to these two parts, students have to gain practical experiences during so called Famulaturen [4months] and a Praktisches Jahr [48 weeks]. After successful completion of the Praktisches Jahr and the second of the two exams required by Art. 1.2 ÄApprO, students earn a medical degree and are allowed to work as physicians in Germany.64 The thesis has as its objective to investigate the economic decision making behavior of physicians with their own medical practices and therefore Art. 1.1 ÄApprO is of particular relevance. This article describes as one of the key objectives of a German medical degree, to “educate prospective medical practitioners in such a way, that they are able to understand the economic consequences of their professional behavior”65. This provision’s objective only came into effect in 2003with a reform of the ÄApprO. This is important because all the doctors interviewed for chapter four of this thesis studied Compare section 2.1.

under a curriculum which did not provide for the objective introduced by the reform of the ÄApprO in 2003.66 Consequently, the physicians interviewed for chapter four should be in a more disadvantaged position to understand the economic scope of their decision making than their colleagues who began studying medicine after 2003.

Another potentially relevant part of the curriculum in explaining doctors’ approach to economic decisions are the Famulaturen, of which at least one has to be accomplished for a one month period in an institution of the ambulant health care sector i.e. a doctor’s surgery. In the case of a one month placement during a Famulatur at a medical practice, it has to be assumed that the extent to which prospective physicians learn about the economic implications of managing a doctor’s surgery is negligible. Furthermore, the expected learning effect heavily depends on the willingness and ability of the doctors in charge of the students during their Famulatur.

During the practical periods of their studies and the time after approbation, in which most physicians work at hospitals, students and young doctors are exposed to a lot of technical equipment and drugs to which, over time, they become accustomed. Furthermore, a lot of suppliers of medical equipment and drugs, as well as service providers are aiming their marketing activities at the prospective doctors during their time at campus and elsewhere to strengthen their brands’ perceptions in the students’ minds.67 Compare Narr (2007), p. 56ff..

Compare for example the website of MLP Finanzdienstleistungen GmbH which offers many services to students in their clinical studies and also subsidize textbooks popular among students: http://www.mlpmedizinstudenten.de/.

As described before, universities which want to offer medical degrees in Germany must follow the rules laid down in the ÄApprO. Deviations from the standard curriculum are an exception rather than the norm, but are admitted in Art. 41 ÄApprO [Modellstudiengänge] if they are approved by the federal legislature. Some universities, such as the Charité – University hospital in Berlin or the RWTH Aachen and the private university of Witten-Herdecke, offer curricula which diverge from the standard curriculum.68 Nevertheless, none of these deviations has as its objective to cater for the increasing importance of economic implications which influence the medical profession, in particular with regard to managing doctor’s surgeries in the ambulant health care sector. Modellstudiengänge rather focus on problem based learning and bedside teaching.

The hypotheses which will be tested with regard to section 3.2.2 are H4 and H5:

H4: University education provides prospective doctors with relevant knowledge in the field of business administration that they need to manage own medical practices.

H5: University education provides prospective physicians with an adequate understanding of the economic implications of their decision making for society.

H6: Doctors try to avoid any form of uncertainty in their economic decision making and are willing to accept only a very limited amount of risk.

Compare the websites of the respective universities.

3.3 The key stakeholders of doctors with their own practices The environment of doctors with their own practices is affected by objectives and expectations of several external stakeholders. It would go beyond the scope of this thesis to provide an in-depth insight into the position of each and every stakeholder and therefore only their most important objectives and expectations will be discussed. It has also to be assumed that the extent to which medical practitioners are influenced by each respective force varies among physicians.69 Patients, politics, statutory health insurances, colleagues and suppliers of medical equipment and drugs are identified as the most important stakeholders of doctors with their own surgeries.70 H7: The perceived impact which external stakeholders have on the work of medical practitioners varies among physicians.

In the description of forces which influence the decision making of doctors, one will avoid discussing the ASHIP in greater detail. Its role as an intermediary between statutory health insurances and politics on the one hand and doctors in the ambulant health care sector on the other hand was extensively discussed in a previous section. The ASHIP inter alia is the political lobby of doctors in the ambulant health care sector and as such follows the same interests as its members. Consequently, no further discussion is required.

Dentists such as Dr. 5 or Dr. 10 offer mainly aesthetic treatments. They do not make decisions that directly threaten their patients’ lives. Consequently, they feel themselves less affected by their stakeholders. However, Dr. 6 and Dr. 1 are specialists who see the lives of their patients endangered, if external stakeholders prevent them from providing patients with all the treatments that they consider being necessary.

Compare Hajen et al. (2008); Warnebier (2007) for a similar line of argument.

3.3.1 Patients Becoming healthy as quickly and as comfortable as possible can be assumed to be the major objective of patients. Furthermore, patients want to minimize their economic impact of being ill.71 The economic impact of illnesses has been of rising importance for patients in recent years for two reasons. First, although the payment of salaries in Germany continues in the case of sick leave, patients cannot rely on this social security for an indefinite period of time and therefore have an incentive to return to work healthy sooner rather than later.72 The second reason why the economic impact has increased is due to extra payments which patients were required to make for their medical treatment in addition to their insurance fee. Extra contributions represent a considerable financial burden to an increasingly large number of patients.73 The most important expectation of patients is to be optimally treated by their doctors.

H8: Patients are treated sub optimally by their physicians because of economic reasons.

Because patients are not in a position to judge the medical treatment which they are given, they have to trust their physicians on a very high level. 74 The very high level of trust which is offered by the German population towards their medical practitioners is also revealed by some surveys.75 -Trust and the inability to discover almost any suboptimal treatment, as well as a correspondingly very high status help to explain the traditionally outstanding role of doctors in society. - Halbgötter in Weiß!

Although trust in the medical profession is, relative to other professions, very high in Germany, for more and more patients the doctors’ job loses its magic and physicians are increasingly seen as regular service providers who exist to optimally treat and satisfy their clients. This trend expresses itself in physicians’ perceived pressure to invest in more attractive and modern facilities, state of the art equipment, more demanding expectations of patients with regard to flexible appointments and an increased willingness to switch doctors.76 Furthermore, patients are increasingly suspicious about the treatment quality they are provided with. -Although they themselves are not in a position to objectively judge the quality of physicians’ treatments, they try to compensate for their disadvantage by relying on modern tools to evaluate the quality of their treatment. The scheduled introduction of an online Ärzte TÜV by a major German Compare Warnebier (2007), p. 74; Steffen (2004), p. 98ff.; Werblow (2004), p. 42.

statutory health insurance and the patients’ interest in such a tool can be seen as an example thereof. The tool provides an online platform for exchanging patients’ views on doctors and is seen extremely critically by medical practitioners who expect such tools to be extremely influential and prone to patients’ subjectivity.77

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Between the objectives of patients and politics there is considerable overlapping. 78 The government is interested in a healthy population and the provision of good ambulant health care to patients for two reasons. First, it is elected and wants to be re-elected by the population and as such should see as its main responsibility to represent the interests of its voters. The second reason why the government is interested in a good ambulant health care system is that healthy citizens and workers have a higher productivity and can contribute more to a nation’s growth and prosperity.

Additionally, a country with low morbidity requires fewer investments in its social security system.

In Germany, the government as the executive and the parliament as the legislative define the framework in which medical practitioners have to act. With regard to this thesis, which limits itself to doctors providing health care to patients who are members of a statutory health insurance, the most important legislative provisions can be found in the Social Security Code, Volume 5 [Sozialgesetzbuch Fünftes Buch - SGB V] which regulates the provision of medical services to members of statutory health insurances.

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